PTA 211

SOAP NOTE
Rebecca Stevens
MEDICAL HISTORY:
R wrist, Hoffman Device
L knee arthroscopy
Hx of afib
DIAGNOSIS:
R rotator cuff tear
Status post 4 weeks
SUBJECTIVE:
Pt, 68 y\o lives at home with wife. Stairs with railing to second floor and bedrooms. Retired.
Very active in hiking, biking, and outdoor sports.
Functional Activities: sports, lifting items up to 50lbs, ADLs
Patient Goals: He is interested in returning to hiking, fishing, golfing, and biking when possible.
Pt expressed a strong desire to return to activities but is not willing to compromise his
surgery.
OBJECTIVE:
GONIOMETRY

AROM
Left
WNL

shoulder
shoulder /
shoulder ABD
shoulder ADD
shoulder IR
shoulder ER
MMT
shoulder
shoulder /
shoulder ABD
shoulder ADD
shoulder IR
shoulder ER

Left
5
5
5
5
3
3

PROM
Right
NTd 2
surgical
precaution

Left
163
170
73
90

Right
95
27
80
20
15

Right
NT

Treatment: 2-3x/wk, HEP, MH, CP, E-stim, strengthening, ROM, transfers and education.
Pt received instruction on HEP and has been compliant. Re-eval on 9/19/13
ASSESSMENT:
Condition: Subacute
Rehab Potential: Good
STG: pain (0-2/10) and swelling
ROM (WNL) and strength (5/6)
LTG: 105 165
IR/ER 70 90
all strength 5/5
Restore normal ADLs and pre-injury status for golfing and other outdoor sopts.
pain to 0-2/10
PLAN OF CARE:
Education: HEP, precautions for sports activities.
Referral:
Discharge Plan: cont of strength and ROM. Th. Ex. as needed.